Scholars Journal of Dental Sciences (SJDS)
ISSN 2394-496X (Online)
ISSN 2394-4951 (Print)
Sch. J. Dent. Sci., 2015; 2(1):10-16
©Scholars Academic and Scientific Publisher
(An International Publisher for Academic and Scientific Resources)
www.saspublisher.com
Research Article
The Periodontal Abscess: Clinical and Microbiological Characteristics
Krishna Kripal1, Sandeep Prabhu S*2, Rakesh M P3, Manasi Y Nandedkar4, Syed Sirajuddin5, Ambica6
1
Professor, 2,3,5,6Post graduate student, 4BDS Graduate, Rajarajeswari Dental College and Hospital, Bangalore, Karnataka,
India.
*Corresponding author
Dr Sandeep Prabhu S
Email: [email protected]
Abstract: Periodontal Abscess is a localized purulent infection in the periodontal pocket that may lead to the destruction
of periodontal ligament, alveolar bone and eventually loss of tooth. The areas of more information and knowledge needed
include, Etiology and categorization, knowledge on the micro flora, evidence based therapeutic approach. Therefore the
aim of the study was to assess clinically and microbiologically characterize the well define cohort of acute periodontal
abscesses. 30 patients with periodontal abscess in CGP (Chronic geneneralized Periodontitis) and CLP (Chronic
Localized Periodontitis) patients screened in the Department of Periodontology, Rajarajeswari Dental College and
Hospital Bangalore. The results showed the frequency of detection of periodontal pathogens in CGP and CLP patients,
F. nucleatum (Fn) was the most prevalent bacterial species (68.4% and 73.2%) followed by P. micros(Pm) (66.4% and
71.9% ), P. gingivalis(Pg) (55.1% and 60.1%), P. intermedia(Pi) (46.3%and 51.3%) and B. forsythus(Bf) (41.2% and
46.4%) respectively. In conclusion periodontal abscess in periodontitis patients are characterized by well defined clinical
and microbiological features.
Keywords: Periodontal abscess, Microbiology, Chronic generalized periodontitis, F. nucleatum, Chronic localized
periodontitis, Pocket depth, Bleeding on probing.
INTRODUCTION
Gingival and periodontal diseases in various
forms have affected the human population since the
dawn of history. The term periodontium originates from
the greek word “Peri” meaning around, and “odont”
meaning tooth. Thus it is the functional unit of tissues
supporting the tooth including gingiva, the periodontal
ligament, the cementum and the alveolar process.
Periodontal
abscess
is
a
localized
accumulation of pus within the gingival wall of
periodontal pocket/localized purulent inflammation in
the periodontal tissues. The periodontal abscess
microbiota is usually indistinguishable from the
microflora found in subgingival plaque in adult
periodontitis [1].
The most prevalent bacterial species identified
in periodontal abscesses, using culture-based or
molecularbased
diagnostic
techniques,
is
Porphyromonas gingivalis, with a range in prevalence
of 50–100% [2, 3, 4, 5].
Other strict anaerobes frequently detected
include
Prevotella
intermedia,
Prevotella
melaninogenica, Fusobacterium nucleatum, Tannerella
forsythia, Treponema spp. Parvimonas micra,
Actinomyces spp. and Bifidobacterium spp. Among the
facultative
anaerobic
gram-negative
bacteria,
Campylobacter spp., Capnocytophaga spp. and
Aggregatibacter actinomycetemcomitans have been
reported as well as gram-negative enteric rods [3, 6].
Periodontal abscess are acute lesions that may
result in very rapid destruction of the periodontal
tissues. These are purulent infections localized to the
gingival, Periodontal / pericoronal regions. The
importance of periodontal abscess in clinical
periodontal practice can be observed by:
High prevalence amongst dental emergencies
and its high prevalence in periodontitis patients[7, 8, 9,
10].
a) It is very closely and commonly related with
periodontitis and periodontal pockets affecting
not only untreated patients but also patients
during active treatment or maintenance [11,
12].
b) It is one of the main causes of tooth extraction
and tooth loss mainly in maintenance patients
are caused by periodontal abscess [11].
c) It is observed that periodontal abscess may
result in complications due to bacteraemia
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Krishna Kripal et al., Sch. J. Dent. Sci., Vol-2, Iss-1 (Dec-Feb, 2015), pp-10-16
which may cause infection in distant locations
[12, 13, 14, 15].
In spite of its high prevalence and importance, the
scientific information available on this condition is very
limited. The areas of more information and knowledge
needed include
a) Etiology and categorization
b) Knowledge on the micro flora
c) Evidence based therapeutic approach.
This in turn helps in better understanding of the
various causes, thus help in classifying the periodontal
abscess, which in turn assist in treatment and prognostic
decision making. The knowledge on the micro flora
leads to the understanding the bacterial mechanisms
leading to the formation of the pus collection.
Based on the available literature it highlight two
clinical types of periodontal abscesses.
a) Periodontal abscesses related to pre existing
periodontal pocket.
b) Those not necessarily associated with
periodontal pockets, in which the impactation of
foreign objects, or alterations in root integrity or
morphology, could explain the formation of the
abscess.
Moreover, periodontal abscesses occurring in
periodontal pockets have been explained by different
etiological theories: exacerbation of a pre-existing
periodontitis [12]; inappropriate periodontal therapy,
mainly prophylaxis or scaling, which can leave calculus
in the deeper parts of the pockets [1]; re-occurrence of
the disease [11]; or the occurrence of super infections,
after systemic antibiotic therapy [17].
Although with all these etiological reasons may
exist, very little effort has been made to analyze each
one separately, which in turn led to confusion in
etiology, diagnosis and choice of treatment options. The
aim of the study was to clinically and microbiologically
characterize the well define cohort of acute periodontal
abscesses.
MATERIAL AND METHODS
Patient Population
Twenty four consecutive patients with a
provisional diagnosis of an acute periodontal abscess in
patients with CGP (Chronic generalized periodontitis)
and CLP (chronic localized periodontitis) were
identified during the period from January 2014 to
September 2014 in the Postgraduate Clinic of
Periodontology at Rajarajeswari Dental College and
Hospital, Bangalore. And included on the basis of the
following criteria
a) Localised pain, swelling and tenderness related
to a periodontal area.
b) Edema, Redness and swelling. Commonly
associated with, a deep periodontal pocket,
showing bleeding and suppuration on probing.
c) Endodontal abscesses were excluded based on
vitality test and radiographic examination.
The patients were excluded based on the
following criteria
a) Endodontal abscesses based on radiographic
examination
b) Vitality tests. Non-vital teeth
c) Use of antibiotic drugs in the previous 4 weeks
Once selected according to the above mentioned
criteria, the clinical variables were recorded and
microbial samples from the abscess were taken.
Microbiological Study
Prior to the clinical evaluation microbiological
samples for anaerobic culture analysis were taken. Two
consecutive paper point (Diadent, number 30,
cellpacked, Maillefer, Korea) were inserted in the
periodontal pocket till they reach the abscess, and were
kept in place for 10sec. The paper points were
transferred in 1.5 ml RTF (Reduced Transport Fluid),
and transported to the laboratory within 2 hrs, where the
samples were dispersed (30 s of Vortex), serially
diluted and plated on Blood agar medium Blood agar
plates were studied after 7 and 14 days of anaerobic
incubation (80% N2, 10% H2, 10% CO2 at 37¾C); and
TSBV plates after 3–5 days of incubation at 37¾C in
air with 5% CO2.
Total microbial counts were evaluated on
blood agar plates On these plates, Porphyromonas
gingivalis,
Prevotella
intermedia,
Bacteroides
forsythus, Peptostreptococcus micros, Campylobacter
rectus, Fusobacterium nucleatum and Prevotella
melaninogenica were identified, primarily based on
colony morphology, and the use of different tests to
confirm the initial identification. Colonies were counted
and the percentage respective of the total flora for each
pathogen was calculated.
Actinobacillus actinomycetemcomitans was
identified on TSBV plates, based on colony
morphology and positive catalase reaction. Every
colony, identified as being one of the studied
periodontal pathogens, was isolated on blood-agar
plates (or TSBV) in order to preserve the strains for
additional tests. In addition, in the first 10 patients,
aerotolerance, gram-staining and morphotype study
(coccoid or rod) were performed on every distinct
colony, in order to add information regarding total flora
composition.
Clinical Evaluation
2 types of clinical variables were assessed.
Subjective clinical variables included
a) evaluation of pain,
b) edema, redness and
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Krishna Kripal et al., Sch. J. Dent. Sci., Vol-2, Iss-1 (Dec-Feb, 2015), pp-10-16
c)
Swelling.
They were assessed using a semi-quantitative scale
ranging from values
a) 1 (none)
b) 2 (mild)
c) 3 (moderate), and
d) 4 (severe).
We had assessed all the subjective clinical
variables, except for pain that was self assessed by the
patient, using the same semi-quantitative scale
described above.
Objective clinical variables included such as
a) Bleeding on probing,
b) Suppuration,
c) Cervical lymphadenopathy,
d) Tooth mobility.
e) Probing depth associated with the abscess site
was also recorded using a manual periodontal
probe (Hu Friedy) to the closest millimeter.
Data Analysis
Data from subjective clinical variables are
expressed as percentage of abscesses/patients in each
category. Quantitative clinical variables, as probing
pocket depth, are expressed. Qualitative clinical
variables (bleeding, suppuration, lymphadenopathy and
tooth mobility) are presented as percentage of abscess
positive for each variable. For microbiological
variables, for each bacterial species, both the frequency
of occurrence and the mean proportion of flora in
positive sites were calculated. Laboratory parameters
were averaged, and the value of each patient was
Fig.1: Abscess with 2nd molar
compared with the normal ranges; when the value was
over the maximum of the normal range, the patient was
considered upranged; the percentage of patient’s
upranged for each variable was obtained.
RESULTS
Study Population
Thirty patients suffering from acute
periodontal abscesses and diagnosed with CGP and
CLP were included in the study. Six female patients
(40%) and eighteen male patients (60%). The mean age
was 48 ranging from 26–65.
Clinical Results
Upon recording the case history, Patients were
asked to report the approximate date of onset of
swelling 67% reported that swelling had occurred
1week before. 20% between 1 week and 10days and
13% were not aware. When the abscess condition was
linked to patient’s periodontal condition abscesses
occurred in untreated periodontitis patients.
In relation to the location of the abscess in oral
cavity 24 (80%) abscesses were associated with molar
teeth and distributed in the upper and lower jaw.
Among abscesses in molar teeth, 10 (42% of the
total sample) were associated with 1st molars, 9 (37%)
with second molars (Fig. 1), and 5 (21%) with third
molar (Fig. 2).
Other affected teeth were: 3 (10%) upper
premolars, 1 (3%) lower premolars, and other 2 (7%)
incisors (fig 3).
Fig.2: Abscess with 3rd molar
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Krishna Kripal et al., Sch. J. Dent. Sci., Vol-2, Iss-1 (Dec-Feb, 2015), pp-10-16
Fig.3: Abscess in lower anterior
Bleeding on probing was observed in 100% of
Sample collection with sterile paper points
65% of CGP patients complained of moderate
abscesses while suppuration was detected in 61% cases
to severe pain. 73% of CLP patients complained of
with CGP and 70% with CLP and mobility in 60% with
moderate pain. (Table 1 & 2).
CGP and 63% in CLP of the cases (Table 3 & 4). A
mean probing pocket depth was 2mm, Ranging from
Swelling observed in all patients with score
4mm to 6mm. In 40% (12patients) of abscesses the
from moderate to sever in 69% in CGP and 88% in CLP
associated pocket was deeper than 7mm.
and edema in 63% in CGP and 80% in CLP individuals
(Table 1& 2).
CGP
100%
50%
CGP
0%
pain
swelling edema redness
Table.1: % of abscesses in each category for each subjective clinical variable in CGP
CLP
100%
50%
0%
pain
swelling
edema
redness
Table.2: % of abscesses in each category for each subjective clinical variable in CLP
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Krishna Kripal et al., Sch. J. Dent. Sci., Vol-2, Iss-1 (Dec-Feb, 2015), pp-10-16
Bleeding
Suppuration
Mobility
Lymphade
0%
20%
40%
60%
80%
100%
Table: 3- % of abscesses positive for each clinical variable in CGP.
Bleeding
Suppuration
Mobility
Lymphade
0%
20%
40%
60%
80%
100%
Table: 4- % of abscesses positive for each clinical variable in CLP.
Regarding the frequency of detection of
periodontal pathogens in CGP and CLP , F. nucleatum
was the most prevalent bacterial species (68.4% and
73.2%) followed by P. micros (66.4% and 71.9% ), P.
gingivalis (55.1% and 60.1%), P. intermedia (46.3%and
51.3%) and B. forsythus (41.2% and 46.4%)
respectively (Table 5 & 6).
70
60
50
40
30
20
10
0
Fn
Pm
Pg
Pi
Bf
Table: 5 - %Prevalence of each studied pathogen in periodontal abscesses in CGP
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Krishna Kripal et al., Sch. J. Dent. Sci., Vol-2, Iss-1 (Dec-Feb, 2015), pp-10-16
80
60
40
20
0
Fn
Pm
Pg
Pi
Bf
Table: 6 - %Prevalence of each studied pathogen in periodontal abscesses in CLP.
DISCUSSION
The periodontal abscess is not a homogeneous
clinical entity. The causes for development of abscess
are multitude in nature. Hence it is important to analyze
and characterize properly the type of abscess involved
for studying this clinical condition. We investigated 3o
periodontal abscess from CGP and CLP with moderate
to severe cases. All the effected patients suffered from
untreated periodontitis.
lower (53.8%)in another study [18]. In a retrospective
study on abscesses developing during the maintenance
phase,it showed that 65% of affected teeth were multirooted. One reason for this high prevalence in molars
could be the furcation involvement, 89% of multirooted
teeth in this study had furcation involvement. In our
study 16% in CGP and 22% in CLP had regional
Lymphadenitis, where as it was found lower than 40%
in the other study [18].
On evaluation of the literature available two
similar studies were available. This study [18] included
62 periodontal abscesses in 55 patients, and this study
[3] followed 20 periodontal abscesses, both clinically
and microbiologically. But in these studies, no data was
available on diagnostic criteria or on the type of abscess
selected.
There are only few studies analyze the
microbiology of periodontal abscess. Authors studied 9
abscesses and found that 63.1% of the flora was strict
anaerobes. Other studies analysed 20 abscesses in 10
patients who had taken antibiotics prior to the study,
and reported 59.5% of strict anaerobes [17, 19]
In the clinical diagnosis of a periodontal
abscess, according to study [18] , swelling and/or pain
were the most frequent complaints. In their study, they
found that most of the abscesses (69.9%) were
diagnosed in a clear acute stage. The rest presented as
diffuse swelling or just redness, but never related with a
sinus tract. Our study also agrees with these findings
and was diagnosed after onset of symptoms.
The bleeding on probing was detected on all
abscesses which are in agreement with the study [3]
.The same was found with the level of suppuration,
which was 61% in CGP and 70% in CLP and 68% in
the mentioned study. The associated pockets in our
study were deeper than 6mm (62 %), and 4-6mm (38%)
reported similar proportions (55% and 35.5%,
respectively) [18].
Regarding tooth mobility we found 60% in
CGP and 63% in CLP. While smith and Davies reported
56.5%, May be due to more severe periodontal
destruction as we only included periodontitis patients
The molars were most commonly involved
teeth in abscesses ranging 42% of the cases. A similar
percentage was found in this study [7], and slightly
All the studies the microflora of periodontal
abscess is characterize of periodontal pathogens.
Among them the most prevelant group of bacteria
Fusobacterium. nucleatum ranging between 68.4% to
73.2%, P. intermedia between 25–100% and P.
melaninogenica (and other black-pigmented Prevotella)
between 0–22% [3,5,17,19,20]. Our data of prevalence
for these species were 50%, 62.5% and 16.7%,
respectively, demonstrating similar presence of these
pathogenic bacteria.
And our data shows the prevalence the species
Fusobacterium.
nucleatum
(73.2%),
Peptostreptococcus. Micros (71.9%), Porphyromonas.
gingivalis (60.1%), Prevotella. Intermedia (51.3%),
Bacteroides. Forsythus (46.4%) in CLP individuals and
Fusobacterium.
nucleatum
(68.4%),
Peptostreptococcus. Micros (66.4%), Porphyromonas.
gingivalis (55.1%), Prevotella. Intermedia (46.3%),
Bacteroides. Forsythus (41.2%) exbhiting similar
pathogens [3,5,17,19,20].
Another study [21] showed that Fn as high
prevalence in periodontal pockets. We found that 68.4%
in CGP and 73.4% in CLP of the abscess. We could not
find A. actinomycetemcomitans in our samples, while
other study reported a prevalence of 25% [3].
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Krishna Kripal et al., Sch. J. Dent. Sci., Vol-2, Iss-1 (Dec-Feb, 2015), pp-10-16
We have also detected B. forsythus in 41.2%
and 46.4% of the patients in CGP and CLP respectively.
While authors found it in a 14.3% of abscesses, using
Polymerase Chain Reaction [20]. Regarding the relative
proportion of the microflora, Fusobacterium. nucleatum
represented the heighst percentage . Lower proportions
are reported for P. intermedia with 8.3% and 7.1% in
CLP and CGP patients in our study. The role of
proteinase producing bacteria, such as P. intermedia,
could be important in the nutritional chain relation [22].
4.
5.
6.
The aim was to charecterise periodontal
abscesses in periodontitis patients. The Periodontal
abscess is a moderately painful clinical condition which
requires emergency treatment in most patients. We
found that molar teeth were most frequently effected
may be due to the influence of a multi-radicular
anatomy. All the abscesses were diagnosed in untreated
periodontitis patients. In all cases we were able to detect
localized area of redness, swelling, tenderness and
edema. It was found that abscesses involved teeth with
severe inflammation, deep probing depth, and
periodontal destruction as evidence by the bleeding and
suppuration.
7.
8.
9.
Regional lymphadenitis is possible but not
common, while an associated increase of leucocytes can
be detected in approximately 1/3 of the patients. The
periodontal abscess microflora is composed mainly of
periodontal pathogens, specially P. gingivalis, P.
intermedia, F. nucleatum, P. micros and B. forsythus
CONCLUSION
Periodontal abscess in periodontitis patients
has clear clinical and microbiological characteristics.
The periodontal abscess depicts typical features, and in
this study was associated with untreated chronic
periodontitis. The more prevalent organisms cultured
from periodontal abscesses were Fusobacterium spp., P.
intermedia/ Nigrescens. However, the presence of
Gram-negative enteric rods may be of clinical
importance. More studies are needed in order to
characterise other types of abscesses and to define
efficient treatment modalities.
10.
11.
12.
13.
14.
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